Provider Demographics
NPI:1396392882
Name:LEE, JI SOO (RBT)
Entity Type:Individual
Prefix:
First Name:JI SOO
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 CAMINITO EASTBLUFF UNIT 179
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2869
Mailing Address - Country:US
Mailing Address - Phone:408-605-1183
Mailing Address - Fax:
Practice Address - Street 1:7090 MIRATECH DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3109
Practice Address - Country:US
Practice Address - Phone:858-304-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-96269106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician